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Rectal prolapse is a distressing condition. Among the multiple corrections described, the perineal approach has generally been abandoned. However, Delorme's procedure is a good, simple and efficient intervention with a low morbidity for certain elderly selected patients. The purpose of this paper is to recall the details of this technique and review its results.
A series of 164 patients with procidentia recti has been studied. Symptoms are sensation of obstruction, difficulties in emptying the bowel, proctitis, incontinence, reduced tonus of anal sphincters, and complete rectal prolapse. During I the rectum prolapses only under increased intraabdominal pressure and retracts spontaneously. Massive prolapse (stage II) often occurs without increased intraabdominal pressure and has to be reposited manually. Best results are obtained by fixing the mobilised rectum in the hollow of the sacrum as described by Wells in 1959 or by Ripstein in 1969. In bad risk patients a sublevatoric wire can be used. Most patients have satisfactory continence postoperatively without a corresponding physiological tonus of anal sphincters.
Recurrent rectal prolapse or postoperative rectal stricture occurred in four of 88 patients (4.5 per cent) who underwent Teflon sling repair at the Lahey Clinic during the past 15 years. Management of these and six other similar patients referred for treatment suggests that young men appear to be at a higher risk for recurrence. Strictures may be more likely to develop in patients with a long history of prolapse or problems with constipation. Teflon sling repair followed by recurrent prolapse or stricture formation should probably be treated by low anterior resection.
Forty-eight patients with rectal prolapse were seen at Ochsner Clinic from 1955 to 1977. The charts of these patients were reviewed to assess the results of treatment and to evaluate a suggested association between rectal prolapse and solitary rectal ulcer syndrome. Since 1970 the Ripstein sling procedure has been used exclusively to treat those patients with rectal prolapse who are able to undergo a transabdominal procedure. We compared the results of this procedure with the ones formerly used: perineal (Altemeer), sigmoidectomy, and Thiersch procedures. Although the earlier operations for rectal prolapse were associated with either a high recurrence or a high complication rate, the Ripstein has both a low recurrence and a low morbidity rate: two patients had recurrence and two had the sling applied too tightly. The Ripstein procedure was shown to be an effective, safe procedure for repair of rectal prolapse, and the result was considered satisfactory by 20 of the 21 patients questioned. Regarding the association of rectal ulcer and rectal prolapse, we found that, although the symptoms of the solitary rectal ulcer syndrome and rectal prolapse are similar, they appear to represent a different response to the same stimulus, and the syndrome is relatively unabated by repair.
Rectal prolapse is common in Nigerian children between 4 and 6 years old. Intractable cases respond favorably to the Lockhart-Mummery procedure, a simple operation which guarantees good results.
Transabdominal proctopexy (Ripstein procedure) for correction of massive rectal prolapse has greatly simplified the complicated problem of managing procidentia. The operation secures the rectum into the hollow of the sacrum by a Teflon sling. This restores and maintains the normal posterior curve of the rectum and prevents intussusception with subsequent prolapse. There has been no recurrence of rectal prolapse and no mortality in 36 patients, half of whom have been followed from five to ten years. Posterior proctopexy is a simple, safe and effective operation to repair massive rectal prolapse.
Whatever the basic pathogenesis of rectal prolapse, the structural alterations invariably include a defect in the pelvic floor fascia, a deep pouch anterior to the rectum, a patulous anus, loose fixation of the rectum to the pelvic structures, and a long sigmoid colon. A variety of corrective procedures have been described for rectal prolapse, but all suffer from various disadvantages. The transsacral approach to the rectum has several advantages: (1) it is simple and safe even for the elderly, (2) it avoids an abdominal incision with its concomitant postoperative complications, (3) it will allow complete correction of all abnormalities, and (4) it has been performed with a low recurrence rate.
We report for the first time the treatment of rectal prolapse by laparoscopically assisted anterior resection. A 52-year-old woman, institutionalized for the last 10 years after diffuse cerebral injury secondary to toxic shock syndrome, developed rectal prolapse. A long life span is anticipated for this otherwise healthy middle-aged woman. Anterior resection was selected as treatment because of the low, long-term rates of recurrence of rectal prolapse. Approximately 2 1/2 ft of sigmoid colon and proximal rectum were resected. The anastomosis was constructed using a double-stapling technique. After surgery, the patient experienced virtually no pain and received only a single injection of pain medicine in the postoperative period. She was started on clear liquids on the first postoperative day and a regular diet on the second. She passed flatus on postoperative day 2 and stool on day 5. She was discharged 7 days after the operation. We believe that laparoscopically assisted anterior resection offers a promising new option for the treatment of rectal prolapse.
Surgery for complete rectal prolapse was performed in 17 women and 3 men between November 1986 and April 1991. An abdominal approach with posterior rectopexy was used in 17. The Thiersch procedure of anal narrowing was performed in 3 high risk patients. All recovered without major complications. Urinary tract infection developed in 15% and postoperative fecal impaction in 10%. Anal continence improved in 70% of those previously incontinent. There was no recurrence of complete rectal prolapse during follow-up. All patients rated the operative results as either good or very good.
The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent full-thickness rectal prolapse, six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, high-risk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.
Functional changes after the posterior abdominal rectopexy for the treatment of rectal prolapse are not fully understood. We studied the effects of Wells' or Ripstein's rectopexy on functional characteristics as related to anal sphincter function, rectal volume and sensory function in 21 patients with complete rectal prolapse. We have observed an improvement of continence over 70 per cent in both groups. However, an absent or a decreased call to stool, constipation and evacuation difficulties are the aftermath of Wells' rectopexy, while these complaints appear basically unaffected by Ripstein's technique. Sensory thresholds for sense of filling and urge were significantly raised after Wells' rectopexy even one year after operation, whereas after Ripstein's operation sense of filling was not significantly affected and while sense of urge was increased early postoperatively, it was not significantly changed at one year postoperative control. In conclusion, when fecal incontinence appears associated to a complete rectal prolapse has good chances to improve postoperatively. Preoperative evacuation difficulties seems to be unaffected by a posterior abdominal rectopexy, Wells or Ripstein, but an extensive dissection of the rectum with the division of the lateral stalks, as it is performed in Wells' operation, seems to be a procedure that can create a further burden of problems to the patient and it seems coupled to a manovolumetric elevation of rectal sensory thresholds.
Anal sphincteric pressure studies of patients with complete rectal prolapse demonstrated that: 1) The resting yield pressure of the internal anal sphincter in patients with complete rectal prolapse was not significantly different from that of control subjects. Thus, it seems to have no role in the etiology of prolapse. 2) The maximal sphincteric pressure of the external anal sphincter was significantly less in patients with prolapse than in controls. This suggested weakness in the effective functional power of the external anal sphincter in complete prolapse. 3) Anal continence could be achieved by the ability to maintain full contraction of the external anal sphincter for more than 40 seconds, which was the minimum for control subjects. Incontinent patients could not do this.
One hundred and twenty-seven patients with complete rectal prolapse have been reviewed. The condition occurred more commonly in females than males (105 to 22), and at an older age in females (mean age 55 years compared with 40 years for males). Although the diagnosis is usually obvious, the importance of recognizing occult prolapse is stressed, especially in association with benign rectal ulcer, localized proctitis and colitis cystica profunda. Examination of the patient in the squatting position may assit in showing occult prolapse. Associated incontinence occurred in 33 patients (26%). Since 1971 the policy of this Unit has been to perform a Ripstein repair for complete rectal prolapse wherever possible. One hundred and two Ripstein repairs have not been performed. A minimum follow-up period of two years is available for 53 patients, of whom 50 (94%) have had their prolapse cured. Control of prolapse usually improves continence; however, seven (13%) remained incontinent despite surgery. The Ripstein repair is strongly advocated as the most effective operation for cure of complete rectal prolapse.
The injection of 5% phenol in oil into the rectal submucosa cured persistent rectal prolapse in 91 of 100 young children. This result supports the view that the common form of rectal prolapse in otherwise-healthy children primarily involves the mucosa and the muscular wall is only secondarily involved.
Eleven patients with full thickness rectal prolapse underwent ambulatory fine wire electromyography (EMG) of the internal anal sphincter (IAS), external anal sphincter and puborectalis muscle, and anorectal manometry using a computerised system. Examinations were performed preoperatively and at 3 months following rectopexy. The median preoperative IAS EMG frequency was 0.21 Hz (range = 0.05-0.30) and the median preoperative resting anal pressure (RAP) was 13 cmH2O (range = 2-84 cmH2O). A significant improvement in the IAS EMG frequency (median = 0.31 Hz; 0.23-0.47 Hz; p < 0.02) and RAP (median = 30 cmH2O; 20-84 cmH2O; p < 0.01) was noted post-rectopexy but these parameters remained significantly different from a group of normal controls (median IAS EMG frequency = 0.48 Hz; 0.25-0.61 Hz; median RAP = 76 cmH2O; 22-120 cmH2O). We suggest that repair of the prolapse allows the IAS to recover by removing the cause of persistent recto-anal inhibition.
There are two schools of thought concerning the aetiology of rectal prolapse. On the one hand it was conceived to be a sliding hernia through a defect in the pelvic fascia, while on the other hand radiological studies have demonstrated prolapse to be represented by an intussusception of the rectum. Various operative procedures have been proposed for the treatment of rectal prolapse based on the belief in one or the other of these concepts. The anatomic defects which have been described with prolapse include a defect in the pelvic floor with diastasis of the levatores ani, loss of the normal horizontal position of the rectum, an abnormally deep cul-de-sac of Douglas, a redundant rectosigmoid, and a patulous anal sphincter. The popularly used procedure in Great Britain is that in which a sheet of Ivalon sponge is sutured to the sacrum and wrapped around the rectum thus anchoring it in place. Various authors have reported good results using this technique. The mortality and morbidity rate appear to be acceptable. In the U.S.A. a popular procedure is the Ripstein technique where a sheet of Teflon is wrapped around the rectum anteriorly anchoring the rectum to the sacrum. This technique also has its proponents who rport satisfactory results. Abdominal proctopexy and sigmoid resection, although not in common general use, has been found to be effective with an acceptable morbidity and mortality rate. These three procedures have some drawbacks but the one problem common to all the repairs so far developed for prolapse is their inability to guarantee to restore continence. Probably half the patients operated upon continue to be incontinent. Faradic stimulation of the sphincter has not proved to be as helpful as initially hoped.
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OBJECTIVE: To evaluate the results after Delorme's operation for rectal prolapse in elderly and unfit patients. DESIGN: Retrospective analysis and telephone interview. SETTING: Akademiska sjukhuset, Uppsala, Sweden. SUBJECTS: A consecutive series of 14 women (median age 82, range 32-92) operated on for rectal prolapse 1987-1992 and followed up after a median of 18 months. RESULTS: There were no serious postoperative complications. Continence was improved in 6/11 incontinent patients. The recurrence rate was 3/14 (21%). CONCLUSION: Delorme's operation is an attractive alternative in elderly or unfit patients, but is not recommended for younger and low risk patients because of the recurrence rate.